Provider Demographics
NPI:1285679449
Name:NGUYEN, TUNG CONG (DO)
Entity Type:Individual
Prefix:
First Name:TUNG
Middle Name:CONG
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9869
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92728-9869
Mailing Address - Country:US
Mailing Address - Phone:714-697-7735
Mailing Address - Fax:
Practice Address - Street 1:2509 W 1ST ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92703-3401
Practice Address - Country:US
Practice Address - Phone:714-541-0057
Practice Address - Fax:714-541-0047
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5784207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOAX57840Medicaid
CAE75387Medicare UPIN
CA20A5784Medicare PIN